Provider Demographics
NPI:1649363680
Name:COMMUNITY PLACE
Entity type:Organization
Organization Name:COMMUNITY PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNE-MICHELLE
Authorized Official - Middle Name:SABATHIER
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:NHA, MHA
Authorized Official - Phone:601-355-0617
Mailing Address - Street 1:1129 LANGLEY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3115
Mailing Address - Country:US
Mailing Address - Phone:601-355-0617
Mailing Address - Fax:601-948-7506
Practice Address - Street 1:1129 LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3115
Practice Address - Country:US
Practice Address - Phone:601-355-0617
Practice Address - Fax:601-948-7506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS53314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0023034Medicaid
MS25-5285Medicare ID - Type Unspecified